Psychological or Neuropsychological Testing Request
Questions? Please call us at 1-800-345-6784
Member Name:
Subscriber ID Number:
Member DOB:
Phone: (
)
Gender:
Age:
Referring Provider Name, Credential:
Male
Female
Tax ID #:
Referring Provider Street Address:
Referring Provider City:
State:
Referring Provider E-mail Address:
Phone: (
)
ZIP:
Fax: (
Referring Provider’s Role with Member (e.g., PCP, Therapist, etc.):
Form completed by:
Provider Administering Tests Name, Credential:
Tax ID #:
)
Testing Provider Licensure (if not a psychologist, include credentials for performing psychological testing):
Testing Provider Street Address:
Testing Provider City:
State:
Testing Provider E-mail Address:
Place of Service:
Phone: (
)
ZIP:
Fax: (
)
Inpatient Facility. If checked, name of facility:
Psychologist’s Office
Outpatient Treatment Center
Other—Describe:
Complete to the best of your knowledge including the current, provisional and/or rule out diagnosis for each axis.
AXIS
DIAGNOSIS
DSM IV Code
Description
Axis I:
Axis I:
Axis II:
Axis II:
Axis III:
Axis III:
CLINICAL INFORMATION
Relevant clinical history including current, specific presenting symptoms that support testing request:
What question(s) is psychological testing expected to answer and how will the test results influence treatment?
Medications:
Anti-Depressants
Anti-Psychotics
Other:
Is patient currently abusing any substances?
Anti-Convulsants
Anti-Anxiety Agents
Mood stabilizers other than anti-psychotics and anti-convulsants
Yes
No
If Yes, describe:
Unless specifically requested elsewhere in this document, please do not send a DNA or other genetic sample, or the results of any genetic typing, test or analysis, including DNA.
Confidentiality Notice: The information contained in this facsimile message is privileged or confidential, and intended only for the individual or entity named above. If the reader
is not the intended recipient, or the employee or producer responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of
this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the number listed on this page.
020957 (09-2009)
Page 1 of 2
An Independent Licensee of the Blue Cross Blue Shield Association
REQUESTED TEST(S) DETAILS
Member Name:
Subscriber ID Number:
Type of Testing:
Psychological
Neuropsychological
Please list or attach list of all proposed tests. For test batteries (e.g., HRNB), list specific subtests of batteries.
Test Name(s):
TESTING
DATES
DISTRIBUTION OF HOURS
Psychological Testing
CPT Code
96101
Neuropsychological Testing
Time
CPT Code
96116
96102
96118
96103
96119
Other:
96120
Time
Total hours of testing requested:
90801 Initial Evaluation Interview Needed?
Yes
No
For CPT Codes 96102 and 96119, please indicate the licensure of the technician or confirm that the technician will be supervised by a licensed
mental health provider whose scope of practice includes psychological testing:
Note: If testing has already been completed, include a copy of the typed testing report.
Initial Evaluation Date:
Testing Date(s):
Feedback Session Date:
Provider Signature:
X
Date:
E-mail this request to:
bhcaremanagement@premera.com
Note: If this is your first e-mail submission, log onto
https://voltage-pp-0000.premera.com/login and
create a secure e-mail account.
Or fax to:
1-800-843-1114 or
1-888-704-2091
Or mail this request to:
Premera Blue Cross
Attention: Behavioral Health
P.O. Box 34299, MS 438
Seattle, WA 98124-1299
Questions? Please call us at 1-800-345-6784
Unless specifically requested elsewhere in this document, please do not send a DNA or other genetic sample, or the results of any genetic typing, test or analysis, including DNA.
Confidentiality Notice: The information contained in this facsimile message is privileged or confidential, and intended only for the individual or entity named above. If the reader
is not the intended recipient, or the employee or producer responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of
this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the number listed on this page.
020957 (09-2009)
Page 2 of 2
An Independent Licensee of the Blue Cross Blue Shield Association